UA136049U - METHOD OF SIMULATION OF CLINICAL SITUATIONS OF OBSTETRIC HEMATOMAS - Google Patents

Abstract

A method of modeling clinical situations of obstetric hematomas using medical phantoms, according to which on the medical phantom of the pelvic organs of a woman with a scalpel and scissors perform an autopsy of the mucous membrane, drain the hematoma cavity with a rubber tube, restore the integrity of the mucous membrane of the internal iliac artery, in particular the selection of a formation that mimics the internal iliac artery, perform a ligature under it and bandage, perform extirpation of the uterus, in particular, gradually isolate and ligate vessels, separate the imitation uterus from the cervix. As a medical phantom of the pelvic organs, women use a model of the pelvic organs of a woman made of foam, where the shape of the model imitates the shape of the uterus and appendages and bladder, and as a medical phantom hematomas of different sizes and locations use rubber balls filled with gelatin and painted red , the first hematoma - vulvar, the second - vulvovaginal, the third - hematoma caused by rupture of the cervix with the transition to the body and spread to the retroperitoneal space, the fourth - hematoma, which occurred in the area of the postoperative suture on the uterus, after previous urgency , and also form imitation of vascular system of pelvic organs. And imitation of vascular system of pelvic organs is formed from tubes made of rubber, and models are placed in the plastic boxes imitating walls of an abdominal cavity and a pelvis.

Description

The useful model belongs to the field of medicine, namely to gynecology and obstetrics, in particular to auxiliary methods and devices, and can be used to simulate clinical situations to improve the experience of doctors, regarding the diagnosis and treatment of women in labor with obstetric hematomas.

Obstetric bleeding, together with preeclampsia and infections, is one of the infamous "triad" of causes of maternal mortality in both developed and underdeveloped countries. This is the leading reason for admission of pregnant women to the intensive care unit (ICU) (Stolieg, 2011; ztaiYi, 2012; 7/eetap, 2016; Man, 2013).

Hematomas were the direct cause of almost 13 95 of 4693 cases of maternal mortality in

United States, documented by the Centers for Disease Control and Prevention's pregnancy surveillance system (Vego, 2015). In Ukraine, the rate of bleeding is approximately 8 95 in relation to the total number of births.

Obstetric hematomas develop within a few minutes, hours after surgery, childbirth and as a result of damage to the walls of surrounding blood vessels (arteries, veins or small capillaries) or unqualified post-operative care to the patient. Hematomas can occur in the extraperitoneal areas of the pelvis, including the paravaginal, paracervical space, the space in the broad ligaments, and can spread to the peritoneum.

The overall prevalence of obstetric hematomas ranges from 1:300 to 1:1000 births. The frequency of occurrence of hematomas larger than 5 cm is 1/1000 cases. Supralevator are less common than infralevator. Risk factors for the occurrence of obstetric hematomas include: episiotomy, instrumental assistance in childbirth, first childbirth, long-term I! childbirth period, macrosomia, blood coagulation disorders, vulvar varicose veins, multiple pregnancy, preeclampsia, obstetric aggression. Etiological factors of the occurrence of hematomas include: direct: episiotomy, forceps or vacuum extraction of the fetus, and indirect: radial stretching of the birth canal during the passage of the fetus.

But up to 80-95 hematomas are associated with the inability to achieve hemostasis, for example, during episiotomy or rupture.

Up to 20,95 cases are due to a hidden rupture of a vessel on whole tissues (Tpakag apa

BMyShap 2012).

There is an international classification of obstetric hematomas by localization: Infralevator - localized below the pt. Yemayog api.

These include hematomas of the vulva, vulvovaginal hematomas, and paravaginal hematomas.

The clinical picture of hematomas of this group is characterized by the onset of symptoms within a few minutes or hours. The speed of diagnosis depends on the severity of the bleeding and the awareness of the medical staff. The symptoms of paravaginal hematomas may be joined by symptoms of hypovolemia. It is important to differentiate this obstetric complication from abscess, pain syndrome after episiotomy, tears and hemorrhoids. These non-specific symptoms can easily be explained by other reasons, which can delay the correct diagnosis.

Supralevator - localized above the Iemaiog api point, can spread retroperitoneally, in the broad ligament of the uterus, the upper third of the vagina. They occur as after childbirth through the natural birth canal, most often after operative assistance in childbirth. They can occur as a result of the rupture of the cervix with the transition to the body. But they can also complicate the postpartum period after cesarean section. During an objective examination, attention will be drawn to the deviation of the uterus up and to the side opposite to the hematoma. Symptoms of hypovolemia and hemorrhagic shock are added to the mandatory signs of supralevator hematomas.

Mandatory laboratory examinations are a general blood test, determination of blood group and Rh factor, and coagulogram.

Additional research methods include ultrasound, CT and MRI (if equipment and specialists are available).

Algorithm for management of patients with suspected obstetric hematoma: determination of hematoma localization, assessment of the growth of its volume in dynamics, constant monitoring of the volume of blood loss.

The first line of treatment includes: infusion therapy based on the principles of providing assistance in case of bleeding; antifibrinolytic agents; vasoconstrictors; blood preparations; installation of a Foley catheter; intravenous analgesia. The measures of the second line of treatment of infralevator and supralevator hematomas may be limited to conservative treatment, in the case of hematoma size not exceeding 5 cm.

In the case of a larger size when an infralevator hematoma is formed, the measures of the second line of treatment are: adequate anesthesia; and surgical treatment followed by vaginal or rectal drainage or tamponade.

With the formation of supralevator hematomas with dimensions of more than 5 cm, in constituent parts

The second line of treatment is surgical hemostasis, abdominal access. Complications of obstetric hematomas include their infection, development of peritonitis, long-term pain syndrome, formation of rectovaginal and vesicovaginal fistulas, phlebitis, and femoral vein thrombosis.

From the state of the art, a well-known phantom for teaching puncture of internal organs under ultrasound control contains a container, a gelatin container filler, and simulators of internal organs in the form of elastic tanks with their own colored liquid fillers. The container is made of material that does not produce acoustic artifacts. Vein simulators are made in the form of thin-walled tubes, which are closed on one side with a clamp (patent of Ukraine for a useful model Mo 95255, published on 10.12.2014). This phantom and the method of its operation are not suitable for use in gynecology and obstetrics to simulate clinical situations of obstetric hematomas.

In the prior art, a medical phantom model for ultrasound visualization of redistribution of blood circulation in splanchnic vessels is known, which consists of a chamber filled with optically transparent tissue-equivalent material, with two elastic, waterproof, sound-permeable membranes fixed on top and on one side of the chamber, and with a system of pipelines located in this chamber and connected to the compressor, which ensures the circulation of artificial blood through the system (patent of Ukraine for a utility model Mo 20549, publ. 15.01.2007). This phantom and the method of its operation are not suitable for use in gynecology and obstetrics to simulate clinical situations of obstetric hematomas.

From the state of the art, a known ballistic simulator of a limb contains a sample of a regulated form of clothing, a layer of 20 95 gelatin, a pant leg of a regulated field form soaked through with gelatin, with a homily placed in it, wrapped around a skin-fat flap of appropriate sizes. At the same time, a beef shank and a skin-fat flap of a pig are used (Ukrainian utility model patent Mo 132576, published on February 25, 2019). This phantom and method

Due to its operation, it is not suitable for use in gynecology and obstetrics for clinical situations of obstetric hematomas.

From the state of the art, a method of creating an anthropomorphic phantom for sonoelastographic examinations is known, which includes modeling pathologically changed affected tissues and healthy tissues surrounding pathologically changed tissues, using materials with different elastic properties, according to which for modeling healthy and pathologically changed tissues, materials of biological origin (patent

of Ukraine on utility model Mo 113586, publ. 10.02.2017). This method is not suitable for use in gynecology and obstetrics to simulate clinical situations of obstetric hematomas.

From the state of the art, a method of creating phantoms for modeling regional anesthesia under ultrasound control is known, which includes the creation of a medical device, namely a medical phantom for modeling ultrasound imaging, interventional sonography, according to which tubular structures with strong reflection are used to simulate the peripheral nervous system during ultrasound imaging signal (increased echogenicity), to simulate a vascular bed, tubular structures are used to ensure fluid movement at different speeds, to simulate the surrounding tissues, a material that is well permeable to an ultrasound beam (reduced echogenicity) and/or biological tissue (for example, meat) is used to the most realistic modeling of the intervention site, dense sheets with strong signal reflection are used to simulate the fascial layers, waterproof with the formation of spaces close to anatomical ones, the elasticity of the materials used is selected to simulate the sonoelastogra physical characteristics, and also use a device with a sensor with an electrical converter to register the contact of the tool and the research object (patent of Ukraine for a utility model Mo 63527, publ. 10.10.2011). This method is not suitable for use in gynecology and obstetrics to simulate clinical situations of obstetric hematomas.

From the state of the art, a method of assessing the state of oral hygiene is known, mainly as an educational visual aid, which includes the staining of dental plaque on the surfaces of teeth with an iodine solution, the assessment of staining using points, the calculation of the hygiene index and its differentiation within a given range. Additionally, a dental phantom is involved, because plaque is simulated by covering the surfaces of the teeth of the dental phantom 5 95 with a solution of starch paste, and the starch paste, like plaque, is colored after drying (patent of Ukraine for a utility model Mo 131934, published on February 11, 2019). This method is not suitable for use in gynecology and obstetrics to simulate clinical situations of obstetric hematomas.

From the state of the art, the known medical phantom of the iliac arteries and adjacent anatomical structures of the small and large pelvis of a woman contains a base, an imitation of the pelvis, and the uterus, fallopian tubes, ovaries, blood vessels, and peritoneum are placed in it. Additionally, the bifurcations of the right and left common iliac arteries, which are branched into the external and internal iliac arteries, contain the right and left ureters, and the vessels and ureters are made removable with fasteners and made of the appropriate material with the possibility of filling with liquid (patent

of Ukraine for utility model Mo 68036, publ. 12.03.2012). This medical phantom is suitable for use in gynecology and obstetrics, however, it cannot be used to simulate clinical situations of obstetric hematomas.

From the state of the art, a known method of modeling clinical situations includes the reproduction of possible anatomical features of the root system of teeth on an endodontic phantom (patent of Ukraine for a useful model Mo 128534, publ. 09/25/2018). As an endodontic phantom, a phantom previously made of epoxy resin and/or glue in a cylindrical model is used, in which variants of the anatomical features of the root system of the teeth are simulated, corresponding to the imagined clinical situation, for which Miller root needles of a simulated curvature corresponding to the individual anatomy of the root canal for each variant are used clinical situation, they are pre-introduced into the form of a cylindrical model of the endodontic phantom, fixed with epoxy resin and/or glue, kept for at least 24 hours. until hardening, after which the root needles are removed and simulated versions of the root canals are obtained on the phantom.

This method is not suitable for use in gynecology and obstetrics to simulate clinical situations of obstetric hematomas.

The basis of a useful model is the task of creating such a method of modeling clinical situations, which takes into account the identified and eliminated shortcomings of the known level of technology, which will allow it to be used for use in gynecology and obstetrics for modeling clinical situations of obstetric hematomas.

З The task is solved due to the fact that a new method of modeling clinical situations of obstetric hematomas using medical phantoms has been proposed, according to which, on a medical phantom of the pelvic organs, women use a scalpel and scissors to perform dissection of an imitation of the mucous membrane, drain the hematoma cavity with a rubber tube, restoring the integrity of the mucous membrane, using a dissector, ligation of the internal iliac artery, in particular, the selection of a formation imitating the internal iliac artery, ligature under it and tying, extirpation of the uterus, in particular, the vessels are gradually isolated and tied, separate imitation of the uterus from the neck, and as a medical phantom of the pelvic organs, women use a pre-made foam dummy of the pelvic organs of a woman, where the shape of the dummy imitates the shape of the uterus and appendages and bladder, and as a medical phantom of hematomas of different sizes and locations, they use balls that are filled with gelatin and painted with red paint, while the first hematoma is vulvar, the second is vulvovaginal, the third is a hematoma that arose as a result of rupture of the cervix with transition to the body and spread to the retroperitoneal space, the fourth is a hematoma that arose in the area of a postoperative suture on the uterus, after a previous urgent caesarean section, and also form an imitation of the vascular system of the pelvic organs, and an imitation of the vascular system of the pelvic organs is formed from tubes made of rubber, and the dummies are placed in plastic boxes that imitate the walls of the abdominal cavity and pelvis .

Simulation of the clinical situation will allow the obstetrician-gynecologist to save the reproductive organ, and often the woman's life, as well as to avoid complications of the operation.

It is thanks to the use of foam as a material for the medical phantom that the phantom is extremely practical and extremely strong, as it does not tear when exposed to sharp surgical instruments. In addition, the structure of the foam phantom resembles the anatomical state of the organs as much as possible, at the same time, the foam phantom is inexpensive and available in the educational process, thanks to which it can be customized for each specialist in professional development.

The use of foam as a material for a medical phantom provides an opportunity to follow the movement of a surgical instrument according to the variants of clinical situations.

Imitation of the vascular system of the pelvic organs from tubes made of rubber allows you to achieve the strength of the imitation, since the rubber does not tear under the action of sharp surgical instruments.

The use of rubber balls filled with gelatin and painted with red paint as a medical phantom of hematomas of different sizes and locations allows to study different hematomas according to the variants of clinical situations.

The set of features of a useful model increases the number of options for practicing organ-sparing surgery per unit of training time when practicing professional skills, since it is based on the implementation of a variety of clinical conditions, excludes spending training time on accompanying medical procedures and a number of side inconveniences. Along with this, the invasiveness of the process is excluded, the probability of damage is reduced, traumatism is excluded, and the functionality of the medical phantom is separately expanded.

Therefore, the set of features of the proposed method, mainly as an educational visual aid, based on the existence of a cause-and-effect relationship with the achievement of a technical result, is significant and meets the "novelty" criterion, as it does not follow from the researched state of the art in an obvious way.

In order to optimize and standardize the diagnosis, tactics of management and treatment of obstetric hematomas, the Perinatal Center of the city of Kyiv offered to hold a theoretical and practical training course "Obstetric Hematomas".

In more detail, the proposed utility model is implemented as follows.

At the beginning of the training, there is a short theoretical presentation that sheds light on the current state of the problem of the lack of an optimal standardized and effective route for a patient with this pathology.

Dummies of pelvic organs and surgical instruments are used for training.

With the help of rubber balls filled with gelatin, painted with red paint, hematomas of different sizes and locations are simulated.

The first is vulvarna.

The second is vulvovaginal.

The third is a hematoma that arose as a result of a rupture of the cervix with a transition to the body, and spread to the retroperitoneal space.

The fourth is a hematoma that arose in the area of the postoperative suture on the uterus, after a previous emergency caesarean section.

Pelvic dummies are disposable, made of foam, their shape imitates the shape of the uterus, its appendages, and the bladder. Dummies are laid out on boards, next to them, the vascular system of the pelvic organs is simulated from rubber tubes.

Dummies are placed in plastic boxes to simulate the walls of the abdominal cavity and pelvis.

With the help of surgical instruments - tweezers, scalpel, scissors, needles with a needle holder - the technique of surgical treatment of obstetric hematomas is practiced. With the help of a scalpel and scissors, dissection of the imitation of the mucous membrane is performed, the hematoma cavity is drained with a rubber tube, a needle and a needle holder - restoration of the integrity of the mucous membrane.

Using the dissector, participants also have the opportunity to practice the skill of ligation of the internal iliac artery, namely, the selection of a formation imitating it, the introduction of a ligature under it and ligation.

With the help of a scalpel, scissors, Kocher and Mikulich clamps, a needle with a needle holder, the technique of extirpation of the uterus is worked out, namely, the step-by-step selection with a scalpel and scissors, ot ligation of blood vessels, separation of the imitation of the uterus from the cervix, for which clamps, a needle holder with a needle are used. For optimal assimilation of the material during the practical training for working on dummies, situational tasks were created, the solution of which involves a comprehensive understanding of the theoretical and practical features of the clinical situation, organizational aspects and planning of the patient's route.

During the training, the participants have the opportunity to make a decision about the algorithm for providing assistance, the scope of surgical intervention, examinations.

An obligatory and important element is the possibility of a debatable solution to each step with a discussion of one's own experience.

Based on this experience, this algorithm can be implemented in modern institutions of the III level of providing obstetric and gynecological care. For optimal assimilation of the material during practical training for working on dummies, situational tasks are created,

the solution of which involves a comprehensive understanding of the theoretical and practical features of the clinical situation, organizational aspects and the planning of the patient's route.

In addition, training participants have the opportunity to improve practical skills. During the training, the participants have the opportunity to make a decision about the algorithm of providing care, the scope of surgical intervention, examinations, the expediency and the way of separation of the placenta. An obligatory and important element is the possibility of a debatable solution to each step with a discussion of one's own experience. The advantage of the patented training is the possibility of maximum immersion in the clinical situation, which allows you to recommend it for improving the qualifications of obstetrician-gynecologists.

The proposed method can be applied for use in medical institutions.

The proposed method is adequate anatomically and clinically.

It should be understood that the examples and embodiments described above are illustrative only and various modifications and changes are suggested to those skilled in the art that are within the scope of this application and the scope of the utility model formulation.

It should be understood that the above information in no way limits the scope of the rights under the application.

Claims (1)

USEFUL MODEL FORMULA The method of simulating clinical situations of obstetric hematomas using medical phantoms, according to which, on a medical phantom of the pelvic organs, women use a scalpel and scissors to perform dissection of an imitation of the mucous membrane, drain the hematoma cavity with a rubber tube, restore the integrity of the mucous membrane, use a dissector to perform a translation ligature of the internal iliac artery, in particular the selection of a formation imitating the internal iliac artery, a ligature is performed under it and bandaged, the extirpation of the uterus is carried out, in particular the vessels are gradually isolated and bandaged, the imitations of the uterus are separated from the neck, and as a medical phantom of the small organs a woman's pelvis uses a pre-made foam dummy of a woman's pelvic organs, where the shape of the dummy imitates the shape of the uterus and appendages and bladder, and as a medical phantom For hematomas of different sizes and locations, rubber balls are used, which are filled with gelatin and painted with red paint, while the first hematoma is vulvar, the second is vulvovaginal, the third is a hematoma that arose as a result of rupture of the cervix with transition to the body and spread to the retroperitoneal space, the fourth - a hematoma that arose in the area of the postoperative suture on the uterus, after a previous emergency caesarean section, and also form an imitation of the vascular system of the pelvic organs, and the imitation of the vascular system of the pelvic organs is formed from tubes made of rubber, and the dummies are placed in plastic boxes, imitating the walls of the abdominal cavity and pelvis.